Hospital inpatient care accounts for the largest share of total health care expenses in the US. In 2012, the average cost per inpatient stay was $10,400 with total aggregated hospital costs of $377.5 billion. (Moore, 2012; and Weiss, 2012) In addition to this expense, transitions from the hospital represent a particularly vulnerable time when patients are susceptible to experiencing adverse events, which is especially true for patients with complex chronic comorbidities. For example, twenty percent of Medicare patients are readmitted to the hospital within 30 days, and 20% of all discharged patients suffer from a preventable adverse event within three weeks of discharge.(Rennke, 2013) Despite national efforts to improve transitions, the hospital discharge process largely remains chaotic, fragmented, and associated with poor outcomes. (Rennke, 2013; Hansen, 2011; Jack, 2009; Kansagara, 2015; Kansagara, 2011; & Kripalani, 2014). Currently, even the highest risk patients leave a complex, acute hospital stay to then arrive in primary care offices that are often neither equipped nor resourced to manage the challenges inherent to such transitions. Indeed, transitioning the highest risk, complex patients will require a paradigm shift in care delivery that is intensive, multidisciplinary, coordinated, and encompasses wrap-around services.(http://www.isc.hbs.edu/health-care/vbhcd/Pages/integrated-practice-units.aspx.)